Antegrade Perfusion Research Articles

Postoperative peri-axillary seroma following axillary artery cannulation for surgical treatment of acute type A aortic dissection

The arterial cannulation site for optimal tissue perfusion and cerebral protection during cardiopulmonary bypass (CPB) for surgical treatment of acute type A aortic dissection remains controversial. Right axillary artery cannulation confers significant advantages, because it provides antegrade arterial perfusion during cardiopulmonary bypass, and allows continuous antegrade cerebral perfusion during hypothermic circulatory arrest, thereby minimizing global cerebral ischemia. However, right axillary artery cannulation has been associated with serious complications, including problems with systemic perfusion during cardiopulmonary bypass, problems with postoperative patency of the artery due to stenosis, thrombosis or dissection, and brachial plexus injury. We herein present the case of a 36-year-old Caucasian man with known Marfan syndrome and acute type A aortic dissection, who had direct right axillary artery cannulation for surgery of the ascending aorta. Postoperatively, the patient developed an axillary perigraft seroma. As this complication has, not, to our knowledge, been reported before in cardiothoracic surgery, we describe this unusual complication and discuss conservative and surgical treatment options.

Surgical correction of ruptured aneurysms of the sinus of Valsalva using on-pump beating-heart technique

BackgroundRupture of aneurysms of the sinus of Valsalva results in abrupt onset of congestive heart failure. On-pump beating-heart surgery may reduce cardiac impairment by maintaining coronary blood flow and avoiding cardioplegia. Herein, we report the operative correction of thirty-one patients of ruptured aneurysms of the sinus of Valsalva, using the on-pump beating-heart technique.MethodsThirty-one patients with ruptured aneurysms of the sinus of Valsalva underwent operative corrections using the on-pump beating-heart technique. In patients with fistula diameter less than 1 cm and no aortic regurgitation, the aorta was unclamped throughout cardiopulmonary bypass(CPB) while receiving antegrade heart perfusion. In remainder of patients, retrograde perfusion was used.ResultsAfter intracardiac manipulation was complete and the nasopharyngeal temperature was raised to 36-37°C, the patients were smoothly weaned off CPB. There were no early or late postoperative deaths. All patients were in New York Heart Association functional class I at follow-up (range, 0.5-1 year). Mild-to-moderate aortic valve regurgitation was observed in one patient. No recurrence of the left-to-right shunt from ruptured aneurysms of the sinus of Valsalva was observed.ConclusionsBeating heart on pump allows adequate examination of the aortic lesion under near-physiologic conditions, allows decrease in ischemia-reperfusion injury and potentially decreases the risk of serious or fatal rhythm disturbances. On-pump beating-heart technique for repair of ruptured aneurysm of sinus of Valsalva is feasible and promising. Antegrade heart perfusion is suitable for patients with a fistula diameter <1 cm and no aortic regurgitation, and retrograde perfusion is suitable for the others.

Pulmonary vasoconstrictor responses

Alterations in the physiological balance to maintain the pulmonary circulation at a normal low pressure level result in an elevation in pulmonary vascular tone. Pulmonary vasoconstrictor responses were analyzed under some experimental conditions, which included microembolism, administration of vasoactive agents, hypoxia, and monocrotaline-induced pulmonary hypertension. It is widely accepted that these responses are highly localized and complex. In the present study, excised canine lung lobes, rat lungs, and pulmonary arterial rings from the rat were employed according to the particular experimental design. The mechanism of the initial rapid elevation followed by a gradual decline in perfusion pressure in microembolism was considered to be related not only to the size of the emboli, but to the degree of mechanical injury of the endothelium. The main sites of constriction of the pulmonary vasculature by several drugs were determined in the pulsatile perfused canine lung lobes, according to the degree of decrease in inflow wave amplitude during antegrade or retrograde perfusion. Further, by applying the same method it was confirmed that the site of hypoxic vasoconstriction is located in the peripheral pulmonary vascular bed between the muscular arteries and veins, which are constricted mainly by serotonin and histamine, respectively. A cross perfusion system was set up, employing two lobes from the same dog, in which normoxic blood was perfused into the hypoxic ventilated lobe and vice versa. As a result, the pulmonary vessels showed a response to ventilation hypoxia that was far more sensitive than that to perfusion hypoxia. The effects of a beta-agonist (isoproterenol) and beta-antagonists (propranolol, pindolol) on hypoxic vasoconstriction were observed. Although pindolol (a vasodilatory beta-blocker) abolished hypoxic pulmonary vasoconstriction, which was similar to the effect of isoproterenol, the mechanism of action of pindolol was suggested to be different from that of isoproterenol. The importance of the K+ channel of vascular smooth muscle and also the endothelium in hypoxic pulmonary vasoconstriction were stressed. In isolated pulmonary artery segments of the monocrotaline-treated rat, the augmentation of sensitivity of the vascular smooth muscle to Ca2+ preceded the occurrence of pulmonary hypertension. Similarly, hyperreactivity to KCl and serotonin was also observed. It was clarified that the hyperreactivity induced by monocrotaline is modified by endothelium-dependent relaxation. Extensive cellular and molecular biological investigations are essential for further progress in this field.

Invited Commentary

Transient or permanent neurologic deficits remain the major cause of morbidity and mortality after complex aortic arch reconstruction. Neuroprotective strategies during aortic arch surgery include hypothermic arrest (HCA) alone, HCA in conjunction with retrograde cerebral perfusion (RCP), or antegrade cerebral perfusion (ACP), moderate hypothermia with ACP, and even normothermic complete arch replacement without circulatory arrest. The ideal method of arterial cannulation and cerebral and systemic protection remain undefined. Several reports document the safety and efficacy of these various approaches. However, large clinical series and laboratory data have suggested several limitations of RCP in aortic arch surgery. Svensson and colleagues [1Svensson L.G. Nadolny E.M. Penney D.L. et al.Prospective randomized neurocognitive and S-100 study of hypothermic circulatory arrest, retrograde brain perfusion, and antegrade brain perfusion for aortic arch operations.Ann Thorac Surg. 2001; 71: 1905-1912Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar] have documented that the brain is incompletely perfused when using RCP. Okita and colleagues [2Okita Y. Minatoya K. Tagusari O. et al.Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion.Ann Thorac Surg. 2001; 72: 72-79Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar] found that the prevalence of transient neurologic dysfunction was significantly higher using RCP when compared with ACP. A recent survey of major aortic centers found 50% preferred selective ACP, 38% used a combination of techniques, and 6% used both HCA and RCP [3Stein L.H. Elefteriades J.A. Protecting the brain during aortic surgery: an enduring debate with unanswered questions.J Cardiothorac Vasc Anesth. 2009 July 29; ([Epub ahead of print])Google Scholar]. Numerous arterial perfusion techniques have been described that allow ACP during aortic arch surgery. These techniques include selective cannulation of the ostium of the innominate artery (IA) or left carotid artery (or both of these arteries), cannulation of the axillary artery, cannulation of the innominate artery, and construction of an arch first graft. Huang and colleagues [4Huang F.J. Wu Q. Ren C.W. et al.Cannulation of the innominate artery with a side graft in arch surgery.Ann Thorac Surg. 2010; 89: 800-804Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar] have described a method of innominate artery perfusion using an 8-mm vascular graft in conjunction with the use of HCA for aortic arch surgery. The majority of patients in this series had type A dissections (34 of 46 patients), 4 patients required surgery for type B dissection, and the remainder had aneurysmal disease of the ascending aorta and arch. The operative mortality rate for this complex set of patients was a respectable 6.5%. Interestingly, there were no reported neurologic complications of either transient or permanent neurologic dysfunction. Although the methods and techniques used by Huang and colleagues [4Huang F.J. Wu Q. Ren C.W. et al.Cannulation of the innominate artery with a side graft in arch surgery.Ann Thorac Surg. 2010; 89: 800-804Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar] have largely been described elsewhere for ACP during aortic arch surgery, the novel idea of attaching a side-arm graft to the innominate artery is unique. The authors suggest that a side-arm graft is preferential to direct cannulation for the following reasons: less risk of damage to the innominate artery, less requirement for manipulation of a cannula, and less risk of stenosis of the IA after tying down the pursestring sutures after de-cannulation. Perhaps these reasons are based more on surgeon preference, as many centers report excellent results with direct cannulation. Indeed, the main benefit of direct IA perfusion is the rapidity in which it may be accomplished in an urgent or emergent situation, which requires aortic arch reconstruction (ie, dissection surgery). In addition, the use of a side-biting clamp, as the authors describe, may be more traumatic to the IA than direct cannulation. Therefore, a side-arm graft may be an over complicated method for ACP for most patients. The authors did illustrate one example in which a side-arm graft would be necessary (ie, those patients with small IA diameters). The authors should be commended on their early series of a unique method to supply ACP during complex aortic arch reconstruction. The absence of any neurologic complications is remarkable in this challenging patient population, and the authors' work contributes to the expanding experience of refining aortic arch surgery. Cannulation of the Innominate Artery With a Side Graft in Arch SurgeryThe Annals of Thoracic SurgeryVol. 89Issue 3PreviewThe purpose of this study was to examine the safety and efficacy of cannulation of the innominate artery with a side graft in arch surgery. Full-Text PDF

Retrograde Arterial Perfusion, Not Incision Location, Significantly Increases the Risk of Stroke in Reoperative Mitral Valve Procedures

A recent report suggested that a thoracotomy approach for reoperative mitral valve (MV) procedures was associated with an equivalent mortality and an unacceptable risk of stroke. We assessed these outcomes in a single institution's experience. From 1992 through 2007, 905 patients underwent reoperative MV procedures. The approach was a median sternotomy in 612 (67.6%), right anterior thoracotomy in 242 (26.7%), and left posterior thoracotomy in 51 (5.6%). Concomitant procedures in 411 patients (67.6%) included aortic procedures in 189, tricuspid procedures in 170, and coronary artery bypass grafting in 90. Hypothermic fibrillation was used in 65 patients. Logistic analysis was used to analyze risk factors and outcomes. Overall mortality was 12.7% (115 of 905), 6.7% (25 of 371) for first time isolated MV reoperations, and 10.1% (50 of 494) for all isolated MV operations. Overall incidence of stroke was 3.8% (34 of 905); 10.9% (9 of 82) with retrograde arterial perfusion and 3.0% (25 of 824) with central aortic cannulation (p < 0.001). For isolated MV reoperations, the incidence of stroke was 4.3% (21 of 494): 2.9% (7 of 241) for antegrade perfusion and 5.5% (14 of 253) for retrograde perfusion (p = 0.15). Risk factors for death were age (p < 0.001), renal failure (p < 0.01), tricuspid valve disease (p < 0.001), chronic obstructive pulmonary disease (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8 to 4.9; p < 0.001), emergency procedure (OR, 2.9; 95% CI, 1.2 to 6.9; p = 0.02), and ejection fraction less than 0.30 (OR, 1.9; 95% CI, 1.1 to 3.3, p = 0.018). Risk factors for stroke were retrograde perfusion (OR, 4.4; 95% CI, 1.8 to 10.3; p < 0.01) and ejection fraction below 0.30 (OR, 2.1; 95% CI, 0.9 to 5.0; p = 0.09). The incidence of stroke in reoperative MV operations is associated with perfusion strategies, not with the incisional approach. Reoperative sternotomy and minithoracotomy with central cannulation are both useful for reoperative MV procedures and are associated with low stroke rates.

Current Role and Outcomes of Ascending Aortic Replacement for Severe Nonaneurysmal Aortic Atherosclerosis

Severe atherosclerosis of the ascending aorta is a challenging issue potentially affecting indications for surgery, operative choices, and patients' outcome. No standard treatment has emerged to date, and uncertainties persist about criteria for selecting patients and procedures. Replacement of the atherosclerotic ascending aorta was performed in 64 patients at time of either aortic (n = 49), mitral (n = 21), or tricuspid (n = 7) valve surgery. Coronary artery bypass grafting was performed in 53 patients, and the majority of patients underwent combined procedures (n = 49). Mean age was 72.0 +/- 7.6 years. The expected operative mortality, by logistic European System for Cardiac Operative Risk Evaluation, was 29.0% accounting for ascending aortic replacement and 13.1% disregarding it. Circulatory arrest under deep hypothermia, eventually combined with either retrograde or antegrade brain perfusion, was required in 61 cases. Early death, stroke, and myocardial infarction rates were 10.9%, 6.3%, and 7.8%, respectively. Factors univariately associated with early deaths were preoperative renal failure requiring dialysis (p = 0.001) and longer cardiopulmonary bypass (p = 0.001) and cardioplegia (p = 0.008) times. Cumulative survival at 1, 3, and 5 years was 86% +/- 4%, 74% +/- 6%, and 68% +/- 8%, respectively. Replacement of the atherosclerotic ascending aorta can be carried out at acceptable mortality rates despite the high rates of preoperative comorbidity and the significant incidence of postoperative complications.

Central aortic canulation in acute type A dissection and the use of selective antegrade perfusion provides superior neurological outcome

Central aortic canulation in acute type A dissection and the use of selective antegrade perfusion provides superior neurological outcome

Hepatic zonation of carbon and nitrogen fluxes derived from glutamine and ammonia transformations

BackgroundGlutaminase predominates in periportal hepatocytes and it has been proposed that it determines the glutamine-derived nitrogen flow through the urea cycle. Glutamine-derived urea production should, thus, be considerably faster in periportal hepatocytes. This postulate, based on indirect observations, has not yet been unequivocally demonstrated, making a direct investigation of ureogenesis from glutamine highly desirable.MethodsZonation of glutamine metabolism was investigated in the bivascularly perfused rat liver with [U-14C]glutamine infusion (0.6 mM) into the portal vein (antegrade perfusion) or into the hepatic vein (retrograde perfusion).ResultsAmmonia infusion into the hepatic artery in retrograde and antegrade perfusion allowed to promote glutamine metabolism in the periportal region and in the whole liver parenchyma, respectively. The results revealed that the space-normalized glutamine uptake, indicated by 14CO2 production, gluconeogenesis, lactate production and the associated oxygen uptake, predominates in the periportal region. Periportal predominance was especially pronounced for gluconeogenesis. Ureogenesis, however, tended to be uniformly distributed over the whole liver parenchyma at low ammonia concentrations (up to 1.0 mM); periportal predominance was found only at ammonia concentrations above 1 mM. The proportions between the carbon and nitrogen fluxes in periportal cells are not the same along the liver acinus.ConclusionsIn conclusion, the results of the present work indicate that the glutaminase activity in periportal hepatocytes is not the rate-controlling step of the glutamine-derived nitrogen flow through the urea cycle. The findings corroborate recent work indicating that ureogenesis is also an important ammonia-detoxifying mechanism in cells situated downstream to the periportal region.

Initial experience of branched endovascular graft for abdominal aortic aneurysm with complex anatomy of proximal neck: planning and technical considerations

The purpose of this report was to demonstrate initial Japanese cases of abdominal aortic aneurysm (AAA) with complex anatomy of proximal neck treated using a Zenith fenestrated endograft with branched endovascular technique and to describe the device's design and technical considerations. Planning and sizing of endografts were performed using high-resolution computed tomography on a three-dimensional workstation. Branched endograft technique combined with reinforced fenestrated device and balloon-expandable stent graft was used in two patients because of challenging morphology for the fenestrated device with a bare stent. Successful exclusion of the aneurysm sac was achieved in both patients with antegrade perfusion in incorporated visceral vessels. Endovascular repair using a fenestrated device with graft material incorporating the visceral arteries is feasible. The combination of the reinforced fenestration and the balloon-expandable stent graft can provide an adequate sealing effect for the compromised anatomy. Initial and midterm results are reported with further follow-up and patient accrual.

Branched Endograft for Aortoiliac Artery Aneurysms

Iliac aneurysms can occur concomitantly in 15 to 20% of abdominal aortic aneurysms. The common iliac arteries serve as the distal landing zones for the iliac limbs of abdominal aortic stent grafts, and for most currently available devices, the maximum treatable iliac size is 20 mm. When the iliac artery diameter exceeds this, alternative landing zones or adjunctive techniques are required to achieve an adequate distal seal and fixation, which typically involves occlusion of the hypogastric artery origin and extension to the external iliac artery. The clinical sequelae of acute hypogastric occlusion mostly involve symptoms of hip and buttock ischemia (claudication), which can occur in up to 40% of cases. In this article, a novel method of endovascular management of common iliac artery aneurysms in the setting of endovascular aortic aneurysm repair is described using an investigational (United States only) iliac branch device that preserves antegrade perfusion to the hypogastric artery to decrease the potential risks of pelvic ischemia.

Immediate Clinical Outcome after Prolonged Periods of Brain Protection: Retrospective Comparison of Hypothermic Circulatory Arrest, Retrograde, and Antegrade Perfusion

We aimed to compare the immediate clinical outcome after different cerebral perfusion methods, and examine the factors affecting the mortality and neurological outcome. Between 1993 and 2006, 339 patients underwent proximal aortic operations using a period of cerebral protection. Among these, 161 patients (mean age of 55 +/- 12 years) who required cerebral protection longer than 25 minutes were included in the analysis. Ascending aorta with or without root was replaced in all patients. In addition, total arch replacement was performed in 36 patients. All patients were cooled to rectal temperature of 16 degrees C. Hypothermic circulatory arrest without adjunctive perfusion was used in 48 patients. Retrograde or antegrade cerebral perfusion was added in 94 and 19 patients, respectively. The mean duration of total cerebral protection was 42 +/- 17 minutes. Overall mortality was 15.5% (25/161) and did not differ among the perfusion groups. There was no difference in the incidence of overall neurological events, temporary neurological dysfunction, or major stroke among the groups. Multivariate analysis revealed that transfusion of >3 units of blood (p < 0.03) was an incremental risk factor for mortality. History of hypertension (p < 0.03), coexisting systemic diseases (p < 0.005), and transfusion of >3 units of blood (p < 0.04) were predictors of temporary neurological dysfunction. In proximal aortic operations requiring prolonged periods of cerebral protection, the mortality and neurological morbidity are not determined by the type of cerebral protection method only. Factors like hypertension and diabetes may play a role in the development of temporary neurological dysfunction.

Distal Leg Protection for Peripheral Cannulation in Minimally Invasive and Totally Endoscopic Cardiac Surgery

The introduction of minimally invasive and totally endoscopic cardiac surgery is associated with increased use of femoral artery perfusion. Selective antegrade perfusion of the cannulated artery may be a helpful strategy to avoid ischemia of the lower extremities. The aim of the study was to evaluate the efficacy of selective distal vessel perfusion under continuous monitoring of oxygen saturation using near-infrared spectroscopy (NIRS). All patients (n = 236) who underwent peripheral cannulation for remote access perfusion and endoaortic balloon occlusion for minimally invasive or totally endoscopic cardiac surgery were prospectively analyzed. Perioperative complications, creatine kinase levels, and major complications at the long-term follow-up were recorded. Minor or major complications of leg perfusion occurred in only 4 patients (1.7%); the complications in 2 of the patients were associated with an additional arterial cannula placed at the contralateral side. NIRS monitoring revealed diminished perfusion in 5 cases. Even patients with complications associated with remote-access perfusion had a rapid recovery, and no residual peripheral vascular complication was detected during follow-up. The use of antegrade selective perfusion of the lower extremity at the side of peripheral cannulation for port-access perfusion and endoaortic occlusion is of utmost importance in patients undergoing minimally invasive or endoscopic cardiac surgery. NIRS monitoring has proved to be very helpful for the diagnosis of impaired leg perfusion.

Treatment of Malperfusion during Surgery for Type A Aortic Dissection

During surgery for acute type A aortic dissection, malperfusion may occur during cardiopulmonary bypass. Retrograde perfusion trough femoral cannulation is considered a predisposing factor. However, this may occur even with antegrade perfusion, because of the presence of multiple flaps or compression of the true lumen by the false lumen. In this particular setting, the aim is to reach a perfusion of the true lumen of the dissected aorta. A technique of epicardial ultrasound-guided direct cannulation of the dissected aorta’s true lumen by a Seldinger technique may help in those cases. We describe the technique with particular interest to the epicardial ultrasound control and the type of arterial cannula to be inserted by the Seldinger technique.

Surgical management and long-term outcomes for acute ascending aortic dissection

We sought to assess early and late survival and cardiovascular-specific mortality after surgical repair of acute ascending aortic dissection and the effect of differences in surgical technique, patient characteristics, and preoperative diagnostic testing. Between 1979 and 2003, 195 consecutive patients underwent repair for acute ascending aortic dissection within 2 weeks of the onset of symptoms. Mean follow-up was 7.0 +/- 5.9 years (range, 0-26 years) and was 100% complete. Patients were aged 62 +/- 15 years on average and were mostly male (66%) and hypertensive (69%). Risk of death early and late after the operation decreased over the study period, with hospital mortality decreasing from 21% to 4% when comparing the first and most recent quartiles (P = .007, chi(2) test for trend). At 1, 5, 10, and 20 years postoperatively, survival was 84%, 69%, 55%, and 30%, respectively, and freedom from cardiovascular death was 86%, 80%, 71%, and 51%, respectively. Additional independent risk factors for death were older age (P < .001), renal dysfunction (P < .003), syncope (P = .007), and peripheral vascular disease (P = .006). During the study period, echocardiographic and computed tomographic diagnostic imaging replaced routine aortic angiographic analysis, and operative techniques involved more frequent use of open distal anastomoses, retrograde cerebral perfusion, earlier restoration of antegrade perfusion, and a conservative approach to aortic arch repair. Freedom from reoperation on the aorta or aortic valve was 93% and 84% at 5 and 10 years, respectively. Early and late survival after repair of acute ascending aortic dissection has improved progressively over 25 years in association with noticeable changes in preoperative and intraoperative management. Aortic reoperations were infrequent during follow-up.

Transaortic Stent Grafting for Distal Arch Aneurysm with Antegrade and Retrograde Extracorporeal Circulation

The purpose of this study was to determine whether cerebrospinal cord injury can be avoided with transaortic stent grafting for distal aortic aneurysm, and whether this technique can be widely used. Seventeen patients underwent distal aortic aneurysm repair with the transaortic stent grafting technique. All patients had a median sternotomy with combined antegrade and retrograde perfusion and selective cerebral perfusion. The stent graft was inserted via an aortotomy at the aortic arch. We evaluated the aneurysms on computed tomography scan 2 weeks and 3 months after surgery. The follow-up period ranged from 3 to 85 months. There was no operative mortality or cerebrospinal dysfunction. Reoperation was performed in two patients. One patient died 15 days after the second operation. Postoperative computed tomography scan showed early thrombosis of the excluded aneurysmal space in 15 (88.2 %) patients. Cerebrospinal cord injury could be avoided by selecting lesions for indications and using a combination of antegrade and retrograde perfusion. This surgical technique is useful for arch aneurysms and can be widely used.

Brain and spinal cord protection during simultaneous aortic arch and thoracoabdominal aneurysm repair

We assessed the surgical and neurological outcome of patients undergoing simultaneous repair of aortic arch and descending thoracic aortic aneurysms (DTAA) or thoracoabdominal aortic aneurysms (TAAA) via left thoracotomy or thoracolaparotomy. During a 6-year period, we performed 32 procedures in 23 male and 9 female patients with DTAA or TAAA with concomitant aortic arch aneurysms. The mean age of the patients was 50.9 years (range, 18-75 years). Twenty-two patients suffered from DTAA, 4 had type-I TAAA, and 6 had type-II TAAA. The entire aortic arch was involved in 12 patients and the distal hemi-arch in 20 patients. The mean diameter of the aneurysms was 6 cm (range, 4.9-7.6 cm). All patients were operated on according to the protocol with cerebrospinal fluid drainage, distal aortic and selective organ perfusion, as well as antegrade brain perfusion. Neuromonitoring was performed by means of motor evoked potentials (MEPs), transcranial Doppler (TCD), and electroencephalography (EEG). All patients survived the surgical procedure and 30-day mortality did not occur. At the end of the procedure, all patients had adequate MEPs, TCD, and EEG. One patient died 47 days after operation due to gastrointestinal bleeding and therapy-resistant coagulopathy. Major postoperative complications like paraplegia or paraparesis, renal failure, and myocardial infarction were not encountered. One patient had a stroke but neurological deficits were irrelevant. Mean preoperative creatinine level was 125 mmol/L, which peaked to a mean maximal level of 130 and returned to 92 mmol/L at discharge. Other complications included bleeding requiring surgical intervention (n = 4), arrhythmia (n = 1), pneumonia (n = 5), and respiratory distress syndrome (n = 2). At a median follow-up of 38 months, all but 1 patient was alive and free of re-intervention. Single-stage repair of aortic arch and concomitant thoracic and thoracoabdominal aortic aneurysms via left-sided thoracotomy or thoraco-laparotomy yields excellent short- and midterm outcomes. Monitoring of cerebral and spinal cord function contributes to improved neurologic outcome.

Axillary Artery Cannulation for Cardiopulmonary Bypass during Surgery on the Ascending Aorta and Arch

Performing axillary artery cannulation, during cardiopulmonary bypass in patients with an atherosclerotic ascending aorta or acute dissection of the ascending aorta and arch, is of growing interest. Our aim is to present our experience, to describe the surgical technique, and to demonstrate the sufficient cerebral and total body perfusion through axillary artery cannulation. Twenty-two patients (17 male, five female) underwent surgical treatment with the axillary technique. The log euro SCORE ranged from 6.77% to 70% (mean 28.28). Nine of these patients underwent elective procedure. Eight underwent aortic surgery for pathologies of the aorta and in one patient we performed combined aortic valve replacement and coronary artery bypass grafting. Thirteen patients underwent emergency operation because of acute dissection of the aorta. Twelve of these patients had a type A dissection (according to Stanford classification) and one patient had a type B aortic dissection. The majority of complications were associated with ruptured dissection of the thoracoabdominal aorta and acute dissection of ascending aorta. Despite preoperative disease states that placed our patients at high risk of stroke and visceral end-organ injury, no clinically demonstrable permanent postoperative deficits were observed. Our patients had no neurological dysfunction, stroke, or other complications. Antegrade cerebral perfusion is of paramount importance in cases of aortic atherosclerosis or aortic dissection. The axillary artery provides an excellent site for safe antegrade perfusion, which may play a role in preventing stroke.

Invited Commentary

The authors describe an operative experience of 181 patients with prior sternotomy who underwent mitral valve operations through a right lateral 4- to 8-cm minithoracotomy [1Seeburger J. Borger M.A. Falk V. et al.Minimal invasive mitral valve surgery after previous sternotomy: experience in 181 patients.Ann Thorac Surg. 2009; 87: 709-714Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar]. The cardiopulmonary bypass support technique used femoral vessel access and retrograde arterial perfusion. In more than 75% of these patients, the mitral operation was done without cross-clamping and with the technique of ventricular fibrillation. The authors report relatively good results—a 30-day mortality of 6.6% and a stroke incidence of 3.8%. Although it is difficult to have a comparable control group, as described in their limitations section, the authors have achieved excellent results in this difficult cohort of patients. Several good points mentioned by the authors should be reemphasized. The importance of a preoperative chest computed tomography scan to evaluate the anatomy and aid in approach planning should not be underestimated. The presence of right pleural disease (due to prior resection or pleurodesis) is a serious contraindication and should lead the surgeon to evaluate a left-sided approach. Finally, this large series reconfirms the efficacy and safety of “ignoring” a patent left interior mammary artery graft and mitigates its presence by the strategy of additional core cooling. I am disappointed, however, that in this large series, central aortic or right axillary arterial cannulation was never used; each approach has the advantage of antegrade aortic perfusion. Although this is a relatively young cohort with presumably less atherosclerotic aortic burden and at low risk for complications from retrograde perfusion, data from our institution and the Cleveland Clinic demonstrate a lower incidence of neurologic complications when overall antegrade perfusion strategy is used. These alternative cannulation techniques are important to have in one's armamentarium; central arterial perfusion provides a good option when femoral or iliac occlusive disease is present. The authors stated that the femoral system was evaluated with preoperative computed tomography, but did not state what happened to these patients when such disease was encountered. The authors are to be congratulated on this fines series. By applying the basic surgical principals of good vision and approach through a relatively virgin operative field, they have achieved excellent results for this cohort of high-risk reoperative patients. Minimally Invasive Mitral Valve Surgery After Previous Sternotomy: Experience in 181 PatientsThe Annals of Thoracic SurgeryVol. 87Issue 3PreviewThis study evaluated the results for minimally invasive mitral valve (MV) surgery in patients who had undergone previous cardiac operations through a sternotomy. Full-Text PDF

Should we consider surgical intervention for spinal cord ischemia due to acute type B aortic dissection?

We present a 46-year-old man with a sudden onset of severe back pain following leg pain. An emergent computed tomography showed acute type B aortic dissection. The true lumen was almost completely occluded because of compression of a massive thrombus in the false lumen. The patient developed paraplegia by the time he was taken into the operation room. After induction of anesthesia, partial cardiopulmonary bypass was initiated, and then the chest was opened via left thoracotomy. The entry was found in the distal aortic arch and was successfully repaired. The descending aorta was replaced with a Dacron graft and antegrade re-perfusion was established in the descending aorta three hours after the onset of paraplegia. The patient recovered uneventfully without any neurological deficit. Paraplegia caused by acute type B aortic dissection is a rare complication. Usually it is treated medically. However, if the true lumen is occluded due to a massive thrombus in the false lumen, multiple malperfusion of the distal organs may occur. In such a case, surgical intervention should be considered to resume antegrade perfusion in the descending aorta as soon as possible.

Tratamiento quirúrgico del tumor renal con extensión venosa

Renal carcinoma accounts for 3% of malignant urological tumors. The existence of tumor thrombus in the venous system is more infrequent, and, despite it was believed until recently its presence worsened the diagnosis of the disease, currently it is accepted that in the absence of metastatic or lymph node disease, surgery is the treatment of choice and potentially curative for these tumors. Between June 2003 and November 2007 eight patients with renal disease and venous thrombus underwent surgery; two of them wereT3c and six T3b; in five of them surgery was carried out in association with the heart surgery team in our centre. Three of them underwent surgery with extracorporeal circulation. Mean patient age was 56 years. Tumor thrombus was grade I in one patient, grade II in 4 patients, grade III in one patient, and grade IV in two patients. In all patients with tumor grade > or = III, as well as two with grade II, surgery was performed in conjunction with the department of heart surgery. The operation with extracorporeal circulation, deep hypothermia, cardioplegia, and antegrade and retrograde brain perfusion was performed in grades III and IV. Midline incision was performed, with or without sternotomy, depending on the level of the thrombus. Hemorrhage was the most frequent perioperative complication. It is essential to know the exact level of the cephalic extreme of the tumor thrombus to design the proper surgical strategy; for that, we can use MRI, CT scan or ultrasound. Therefore, surgical approach, multidisciplinary cooperation and use of extracorporeal circulation will depend on such extension of the thrombus and concurrent factors of the patient. A good surgical strategy, as well as early surgery may avoid the use of venous filters preoperatively. Venous wall invasion seems to be related with a greater incidence of lymph node disease, but these patients are candidates to intention-to-cure radical surgery. Thrombus level is not a prognostic factor per se, but it should be taken into consideration for surgical planning. After radical surgery survival rates achieved are similar to those of tumors without venous thrombus.